Information Collection

Facing Financial Shock Applicant Recruitment Survey (CMS-10900)

IC 269319 under ICR 202609-0938-011 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10900 CMS-10900.Applicant Screener Survey (7-9-24) Facing Financial Shock Applicant Recruitment Survey (CMS-10900)	Form and Instruction
CMS-10900 CMS-10900.Applicant Screener Survey (7-9-24) CMS-10900.Applicant Screener Survey (7-9-24).docx	Form and Instruction
CMS-10900. ICR Template_A11 Section 280 Submission Template (7-9-24).docx CMS-10900. ICR Template_A11 Section 280 Submission Template (7-9-24)	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10900				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10900. ICR Template_A11 Section 280 Submission Template (7-9-24)		07/10/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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